Form Phs-7039 - Application For Allotment Of Pay (Page 2 of 2) in pdf

Form Phs-7039 - Application For Allotment Of Pay Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service Commissioned Corps

Division of Commissioned Personnel

Privacy Act Statement

PHS-7039, Application for Allotment of Pay

(For Additional Montgomery G.I. Bill Benefits)

General:

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a).

This form is part of the following system of records:

09-40-0001, Public Health Service Commissioned Corps General Personnel Records, HHS/PSC/HRS, and

09-40-0006, Public Health Service Commissioned Corps Payroll Records, HHS/PSC/HRS.

Authority for Collection of Information:

Title 37, U.S. Code, Section 704 (P.L. 87-649 Revision and Codification of Title 37 -- Pay and Allowances of

Uniformed Services), and Executive Order 9397.

Principal Purpose and Routine Uses:

The information you are requested to supply on this form will be used to process your allotment of pay to the

Department of Veterans Affairs for additional benefits under the Montgomery GI Bill.

Effects of Nondisclosure:

Disclosure of your Social Security Account Number (SSAN) is mandatory. The SSAN is requested for identification

purposes. Failure to supply complete and accurate information may result in delays and/or denial of request.

PHS-7039 (3/02)

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Form Phs-7039 - Application For Allotment Of Pay Page 2